*The following blog was written for our client Movement is Life*
In 2014, large bipartisan majorities in Congress passed the Medicare Access and CHIP Reauthorization Act. This legislation, also known as “MACRA,” represents the federal government’s most significant effort yet to transform our healthcare system away from payment to clinicians based on volume of services provided and instead pay clinicians based upon the value of the services they offer.
The notion is quite simple: the government wants to reward cost-effective clinicians whose patients have healthy outcomes. On paper, this is a great idea. However, figuring out how to execute this policy is not so simple. In order to reward the best clinicians, you have to first identify who exactly is the best and why. This more difficult part is left to the Department of Health and Human Services (HHS), which has the enormous task of creating a standardized way to evaluate every single clinician in this country.
However, this is not the first time our government has undergone a task like this. While this pay-for-performance concept is relatively new to healthcare, educators have been grappling with similar policies for over a decade now.
One of the core components of the No Child Left Behind Act (NCLB), linked school funding to performance on standardized tests. The goal of the legislation was to increase teacher accountability, improve individual outcomes, and close the performance gap in education.
While NCLB and MACRA are very different pieces of legislation, they share the same key concept: that the government can utilize standardized scoring and incentives to encourage better performance. Given our decade of experience implementing NCLB, what lessons can we identify from that program, as we implement MACRA and other value-based healthcare policies?
A common criticism of the NCLB, was that it forced teachers to “teach to the test” placing too much emphasis on high test scores, and not enough on genuine learning. Additionally, schools and teachers began focusing more on the so-called “bubble” students – students that with additional attention the teachers believed were more likely to pass the standardized testing – and ignoring the highest and lowest performers whose testing result was likely pre-determined.
Movement is Life is concerned that we will see this phenomenon repeat itself in healthcare. Instead of using their medical judgement, clinicians will just “provide care according to the metrics.” Instead of viewing all their patients as worthy of their full medical attention, clinicians may just want to care for the patients that can improve their scores.
Furthermore, there is a plethora of evidence which shows that physicians already have racial bias when it comes to recommending procedures or courses of treatment. Which is just one of many factors that contribute to racial health disparities in this country. With the advent of poorly structured payment incentives this bias will become even more pronounced. Clinicians will view minority and impoverished patients as risks, and seek to minimize their exposure to those types of patients – a behavior sometimes referred to as “lemon dropping” by the medical community.
MACRA and other value-based payment reforms have laudable goals, but as currently constructed, they will only further exacerbate health disparities, not minimize them. HHS and Congress need to reward clinicians who aren’t afraid to see “riskier” patients. Unintended consequences of standardized scoring ultimately doomed No Child Left Behind which was repealed by Congress in 2015. If we are to avoid repeating the same mistakes in healthcare, we must carefully analyze how these value-based policies might not work as intended.
As we develop the value-based healthcare models of tomorrow, we should learn from the failed education models of yesterday.